Hospitalists and intermediate care prove to be a good fit

The issue: Balancing patients' need for complex care with the limited resources of the general
ward and the limited space of the intensive care unit (ICU).

Background

“The patients admitted to the [medical] center were increasingly complex and
some of them should receive more intensive care and monitoring,” said hospitalist
Juan Felipe Lucena, MD. “They were low-risk patients for ICU admission but
with significant potential for major complications.”

To provide the appropriate level of care for these patients, the hospital opened a
nine-bed intermediate care unit (ImCU) adjacent to the ICU. The ImCU was not a new
invention, but the Spanish team put an unusual spin on the concept by having the unit
staffed entirely by hospitalists.

How it works

“The unit's work is based on a multidisciplinary co-management model. We think
this is the novel concept of our ImCU,” said Dr. Lucena. Patients are admitted
to the ImCU by an attending hospitalist, but he or she is joined on rounds by the
hospital pharmacist, a nurse, the ImCU resident, and any relevant specialist.

Patients are admitted to the ImCU based on intermediate care criteria established
by the Society of Critical Care Medicine. Their most common admission diagnoses, according
to a study of the ImCU published online in January by the Journal of Hospital Medicine, were respiratory failure (33.6%), sepsis (19.3%), cardiovascular problems (15.8%)
and perioperative care (12.9%).

Each bed on the unit has central monitoring of telemetry, pulse oximetry, arterial
blood pressure and central venous pressure, as well as noninvasive pressure support
ventilation. The nurse-to-patient ratio is 1:3.

Results

The Spanish team reported on the effects of their new unit in the JHM article. Mortality among the 456 patients treated and studied on the unit was 20.6%,
while the expected mortality rate for these patients (based on the Simplified Acute
Physiology Score II) was 23.2% (P<0.001), the study found.

“Although it is very difficult to evaluate the results on mortality in a retrospective
study, we think the encouraging results were in part due to the continuous assistance
of hospitalists through different levels of care from the general ward to the ImCU,”
Dr. Lucena said.

Nurses, who could bring any problems or questions to the attending hospitalist, and
specialists, who could focus more on the specialty-specific care, were other beneficiaries
of the new system.

Challenges

Although most of the work in the ImCU was well-suited to hospitalists (“They
are the best specialists for the triage as well as for the follow-up of these patients,”
said Dr. Lucena), they did lack intensivists' expertise in a few tasks, such as some
procedures.

The ImCU hospitalists also had the occasional conflict with their critical care colleagues
about the allocation of patients. “Although the ImCU could reduce costs and
improves ICU utilization for sicker patients and also potentially decreases ICU readmissions,
problems were derived from the overlap with the ICU team in the triage of some acutely
ill patients,” Dr. Lucena said.

Next steps

Further research is needed to support these assumptions about the cost-effectiveness
of ImCU care, Dr. Lucena said, since his group did not look at that question and existing
evidence is limited. The research team also called for larger, prospective trials
to confirm the improvement in outcomes they found.

“It is important to remember that the data were based on prognostic scores,
and these scores could also have important limitations predicting mortality,”
said Dr. Lucena.

How others benefit

The data did reveal some unexpected advantages to the hospitalist ImCU. Significantly
more patients were co-managed by medical and surgical teams at the end of the four-year
study than they were at the start (34.9% in 2006-2008 vs. 65.1% in 2008-2010). In
addition, the rotation of residents through the unit increased the number of residents
being instructed by hospitalists.

“The significant increase in the perioperative co-management model with different
surgical teams and also the increase in the number of training residents rotating
in the ImCU were wonderful and unexpected results,” said Dr. Lucena. “The
creation of an ImCU can serve as an expansion of role for hospitalists, and also many
clinicians, trainees and patients may benefit from this unique level of care.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.